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Definition: failure to conceive after one year of regular, unprotected intercourse.
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Etiology: males 40% - abnormal spermatogenesis. Females - anovulatory cycles or ovarian dysfunction = 30%, congenital or acquired disorders.
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DX: hysterosalpingography to evaluate tubal patency or abnormalities.
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Management: 1. Clomiphene — induces ovulation. 2. If amenorrhea or oligomenorrhea, correct endocrine problems. 3. In vitro fertilization
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Ladin’s sign
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Uterus softening after 6 weeks
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Hegar’s sign
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Uterine isthmus softening after 6-8 weeks
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Piskacek’s sign
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Palpable lateral bulge or softening of uterine Cronus 7-8 weeks
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Goodell’s sign
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Cervical softening due to increased vascularization, 4-5 weeks
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Chadwick’s sign
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Bluish coloration of cervix and vulva, 8-12 weeks
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Fetal Heart tones
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10-12 weeks, normal = 120-160 bpm
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Pelvic Ultrasound
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Fetus detected 5-6 weeks
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Fetal Movement
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16-20 weeks
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12 weeks
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Above pubic symphysis
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16 weeks
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Midway between pubis and umbilicus
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20 weeks
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At umbilicus
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38 weeks
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2-3 cm below diploid process
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Estimated Date of Delivery (Naegle’s Rule) : 1st day of LMP + 7 days - 3 months
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Blood pressure
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Blood type & Rh
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CBC
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UA (glucose & protein)
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Random glucose
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HBsAg — hepatitis surfaced antigen, measures acute or chronic
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HIV
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Syphilis
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Rubella Titer
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Sickle cell and cystic fibrosis screen
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PAP smear
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Rh(D) negative women carry Rh(D) positive fetus —> exposure to fetal blood mixing D-positive RBCs
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Causes maternal alloimmunization and maternal anti-Rh(D) IgG antibodies
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Subsequent pregnancies —> antibodies may cross placental and attack fetal RBCs = hemolysis of fetal RBCs
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If mother is Rh(D) negative and father is Rh(D) positive, 50% chance
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Anti-D Rh immunoglobulin (RhoGAM) 300 micrograms given @ 28 weeks, within 72 hours of delivery of Rh(D) positive baby, AND after any potential mixing of blood (spontaneous abortion, ectopic pregnancy, amniocentesis, etc.)
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Free beta-hCG
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Abnormally high or low may indicate chromosomal abnormalities
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PAPP-A
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Serum pregnancy-associated plasma protein-A — Low with fetal Down syndrome
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Nuchal translucency US
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10-12 weeks — trisomies 13, 18, and 21. Increased thickness = abnormal, offer chorionic billows sampling or amniocentesis.
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Fetal US
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10-12 weeks , transvaginal can detect at 5-6 weeks after LMP
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Uterine size and gestation
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If abnormal, offer CVS or amniocentesis
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CVS
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10-13 weeks if abnormalities or if at increased risk of abnormalities (>35 yo)
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Triple screening @ 15-20 weeks
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Alpha-feta protein: if high, indicates open neural tube defects / spina bifida. Beta-hCG: high = Down syndrome/ trisomy 21, low = trisomy 18. Unconjugated Estriol: often low in trisomy 21 and 18.
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Gestational Diabetes @ 24-28 weeks
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1 hour & 3 hours abnormal = >140
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Repeat antibody titers
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In RH(D) negative, antibody negative —> give RhoGAM 300 micrograms @ 28 weeks
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Hemoglobin & Hematocrit
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35 weeks
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Group B Streptococcus
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36 0/7 to 37 6/7 weeks, if positive —> prophylactic abx during labor w/in 4 hours of delivery with IV PCN G 5 million units, then 2.5 million units every 4 hours. Second line = Ampicillin, Cefazolin, Clindamycin, Vancomycin
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Biophysical Profile
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Fetal breathing, fetal tones, amniotic fluid levels, NST, and gross fetal movements (2 points each)
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Non-stress testing
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Reactive Test: >/= 2 accelerations of fetal HR >/= 15 bpm from baseline lasting 15 seconds over 20 minutes — fetal well being, repeat weekly-biweekly. Nonreactive test: No fetal HR accelerations or </= 15 bpm lasting < 15 s— indicates sleeping, immature, or compromised fetus —> vibratory stimulus to wake or contraction stress test.
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Contraction Stress Testing
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Negative test: No late decelerations in presence of 3 contractions in 10 minutes = fetal well being. Positive CST: repetitive late deceleration following >/= 50% of contraction = worrisome, hospitalize for fetal monitoring or delivery.
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Braxton Hicks
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Spontaneous uterine contractions late in pregnancy not associated with cervical dilation
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Lightening
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Fetal head descending into the pelvis causing a change in abdomen’s shape and sensation
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Ruptured Membranes
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Sudden gush of liquid or constant leakage of fluid
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Bloody Show
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Passage of blood-tinged cervical mucus late in pregnancy, occurs with cervix is thinning (effacement)
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True Labor
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Contractions of uterine fundus with radiation to lower back & abdomen. Regular + painful contraction of uterus causes cervical dilation and fetus expulsion
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Engagement
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When the fetal presenting part enters the pelvic inlet
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Descent
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Passage of the head into pelvis (lightening)
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Flexion
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Flexion of head to allow smallest diameter to present to pelvis
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Internal Rotation
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Fetal vertex moves from occiput transverse position to position where the Sagittarius suture is parallel to the anteroposterior diameter of pelvis
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Extension
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Vertex extends as it passes beneath the pubic symphysis
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External Rotation
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Fetus externally rotates after the head is delivered so that the shoulder can be delivered
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Expulsion
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Of fetus and placenta
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Stage 1: Onset of labor (true contractions-cervical dilation @ 10 cm
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Latent phase: cervix effacement with gradual cervical dilation. Active Phase: rapid cervical dilation (begins @ 3-4 cm)
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Stage 2: full dilation-delivery of fetus
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Passive Phase: complete cervical dilation to active maternal expulsive efforts. Active phase: from active maternal expulsive efforts-delivery of fetus.
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Stage 3: postpartum until delivery of placenta (0-30 mins)
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Signs of placental separation: 1. Gush of blood. 2. Lengthening of umbilical cord. 3. Anterior-caphalad movement of uterine fundus (becomes globular and firm) after placenta detaches.
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Stage 4: after delivery
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Mother is assessed for complications, 1-2 hours after
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